If your patient develops end-stage renal disease, she may require hemodialysis or peritoneal dialysis to prolong her life. The physician probably won’t recommend dialysis until your patient’s serum creatinine level is about 6 mg/dl.

Hemodialysis

For hemodialysis, the surgeon creates an arteriovenous (AV) access site, usually in the patient’s arm, as shown. With each hemodialysis treatment, a needle is inserted into this AV access site. Blood is withdrawn through the arterial line and pumped through a semipermeable membrane in the hemodialysis machine. As the blood is pumped, dialysate moves through the membrane in the opposite direction, allowing body wastes to move by diffusion from an area of high concentration to an area of low concentration.

The pores in the membrane allow electrolytes, blood urea nitrogen, and creatinine to be filtered out, but they prevent larger particles such as blood cells and protein from passing through. The filtered blood is then returned to the patient through the venous line.

Hemodialysis can be performed in your patient’s home or in a medical facility. Treatments average 3 to 4 hours, three times each week.

Peritoneal Dialysis

In this closed-drainage procedure, a catheter is placed through an opening in the abdominal wall. At regular intervals, dialysate is instilled into the peritoneal cavity. Through osmosis and diffusion, fluid, electrolytes, and waste products are drawn from the blood, across the peritoneum, and into the dialysate. The peritoneum, which lines the peritoneal cavity, acts as a semipermeable membrane. The dialysate is drained regularly and replaced.

Most patients tolerate peritoneal dialysis better than hemodialysis. The patient’s blood pressure usually remains stable, and she experiences less cardiovascular stress and better control of her blood glucose levels. She’ll also have a decreased risk of retinal hemorrhage because she won’t need the higher doses of heparin that are used with hemodialysis. However, peritoneal dialysis places the patient at higher risk for developing an infection, such as peritonitis.

Usually, transplant patients take immunosuppressive drugs to prevent the transplanted organ from being rejected over the long term or to treat incipient rejection. They may start to take these drugs before surgery and continue throughout the life of the organ. Methylprednisolone and azathioprine are usually administered I.V. during surgery. As kidney function improves, the patient takes cyclosporine. Maintenance immunosuppressive therapy usually combines prednisone, azathioprine, and cyclosporine. Patients receiving tacrolimus have less risk of organ rejection and new-onset Type 1 diabetes.

Review the onset, peak, and duration of action of the insulin your patient uses. When her insulin is at peak effect, check her for signs and symptoms of hypoglycemia. Be familiar with oral antidiabetic drugs that can cause hypoglycemia, such as sulfonylureas. Whether she uses insulin or oral antidiabetic drugs, monitor her blood glucose level before meals and at bedtime and tell her to do the same at home.Advise your patient to administer her insulin and oral antidiabetic drugs on time. Patients should eat 5 to 30 minutes after insulin administration, depending on the type of insulin. For example, a patient should eat within 5 minutes after taking Humalog or 30 minutes after taking regular insulin. If your patient leaves the hospital unit temporarily, make sure she takes her insulin and eats her meals on schedule. If a meal will be delayed, give her a snack. Also, provide betweenmeal and bedtime snacks, if needed, at the time of insulin’s peak activity.

If your patient isn’t allowed anything by mouth before a procedure, contact her physician to obtain changes in orders for her insulin and oral antidiabetic drugs.

Patient Teaching

Teach your patient and her family how to prevent, recognize, and manage hypoglycemia . Making your patient an active participant in her care will help her counter feelings of helplessness and loss of control. Enlist her family’s help and ease their fears by teaching them about hypoglycemia as well.

If your patient experiences hypoglycemia, help her identify what may have caused it. Even mild hypoglycemia will disrupt her daily routine if it occurs frequently. Anticipating hypoglycemia without understanding its causes and treatment may affect her compliance with her regimen. For example, she may be afraid to inject insulin for fear of another hypoglycemic episode.

Assess your patient for administration problems, such as administering too much insulin or too high a dose of an oral antidiabetic drug. Ask her to demonstrate how she administers insulin. Also, discuss the timing, quantity, and content of her meals as well as the extent and timing of exercise.

Encourage your patient to monitor her blood glucose level regularly and whenever she experiences hypoglycemic symptoms. Such monitoring will help her learn her threshold for hypoglycemia and recognize her typical symptoms at various glucose levels. Then when she experiences hypoglycemia, she can treat it appropriately.

Teach your patient to recheck her blood glucose level 15 minutes after taking a rapidly absorbed carbohydrate. Encourage her to keep rapidly absorbed carbohydrates, such as hard candies or glucose tablets, available at home and to carry them with her when she goes out. Also, advise the patient to carry a nonperishable snack, such as a package of peanut butter crack­ers, to eat in case a meal isn’t available within 1 hour after a hyperglycemic episode.

Identify a family member or friend who can help your patient if she develops hypoglycemia. Teach this person how to prepare and administer glucagon if hypoglycemia hinders the patient’s ability to swallow. Warn the patient that nausea is a common adverse effect of glucagon; she may need to take small sips of a carbonated, uncaffeinated soft drink until her nausea subsides.

For an elderly patient who lives alone, identify someone who’s willing to learn about hypoglycemia and check on her regularly. Encourage your elderly patient to contact the physician if she experiences frequent hypoglycemia. Also, instruct her to notify the physician if her blood glucose level falls below the target level more often than prescribed guidelines permit. The patient’s drug dosage may need to be adjusted.

Advise your patient to buy a medical alert bracelet or necklace that describes her condition and lists the physician’s phone number-especially if she’s prone to severe hypoglycemia.

When your patient leaves the hospital, give her written discharge instructions about diet, exercise, drugs, blood glucose monitoring, and signs, symptoms, and treatment of hypoglycemia.

Base your diet recommendations on treatment goals designed specifically for your patient . Consider the various roles of proteins, carbohydrates, fats, sweeteners, fiber, sodium, and alcohol in your patient’s diet.

Cultural and Ethnic Considerations

Each patient’s cultural and ethnic background strongly influences her food customs, eating rituals, food preparation, and body image. Religion also can affect dietary habits. For example, Hindus are vegetarians, and Orthodox Jews follow kosher dietary laws.

Family traditions may dictate mealtime habits and foods to be eaten or avoided. A patient’s finances, social status, and geographic region affect the type and availability of foods she eats, as well. The health care team performs a thorough nutritional assessment of cultural and ethnic practices and incorporates them into a personalized nutritional plan.

Food Labels

The Food and Drug Administration’s requirements for food labels have made a big difference to patients with diabetes as they shop for food. The information on labels is useful not only for assessing individual products but also for comparing ingredients of similar products and of different brands of the same product.

Show your patient several labels of healthful and less healthful foods. Point out that many imported foods lack nutritional information.

Ingredients on food labels are listed in descending order by weight. Determining total sugar content may take some analysis, however, because different forms can be listed separately. Give your patient a list of sugar’s many names, including sorghum, sucrose, lactose, and maple syrup. Explain that foods labeled dietetic aren’t necessarily sugar-free and that natural doesn’t mean sugar-free. Cane sugar, for example, is natural. Dietetic foods are usually more expensive, and they’re unnecessary for patients who make an effort to choose foods intelligently.

Food labels also list the number of calories, total fat content, and amount of saturated fat per serving. The difference between total fat and saturated fat is the portion that consists of polyunsaturated or monounsaturated fats. The polyunsaturated and monounsaturated fat content should be greater than the saturated fat content. Also listed are levels of cholesterol, sodium, total carbohydrate, fiber, sugar, and protein.

A food label promising no cholesterol can be misleading. Vegetable oils containing no cholesterol, for example, may be high in saturated fats. Also, teach your patient to scrutinize labels claiming that a food is a certain percentage fat free. A product that is 75% fat free contains 25% fat by weight-and even more than 25% of the total calories may come from fat. The total calories from fat, listed next to the total calories on the label, will give your patient a clearer picture of fat content. Teach her to carefully read labels boasting fewer calories, light, or lite.

Besides ingredients, food labels now list details of nutritional content. This information makes it easier for your patient to choose foods in accordance with her treatment goals.

The information on the food label is based on the serving size, which appears at the top of the food label. Make sure your patient understands that the nutritional content of the entire package isn’t being described unless the label states that the container has only one serving. The percent of daily value listed on the label is based on a 2,000-calorie diet; teach patients with a different calorie plan to take this into consideration.